Many ways to help conference 2016 Melbourne Pathways model update Alexander Blaszczynski PhD Director, Gambling Treatment Clinic & Chair, Responsible Gambling Reard Group
Disclosures & Conflicts of Interest › Financial & professional dealings with gambling industry & State and Federal governments directly & indirectly over the last three years: - Research funding, personal fees for professional consultancy, honoraria for grant reviews & theses examination, royalties for published books, & funding & expenses covered to attend & present at conference & government meetings › Government departments or agencies funded by governments: - NSW Office of Liquor, Gaming, & Racing, Australian Institute of Family Studies, Gambling Research Australia, Australian Department Social Services, Ministerial Expert Advisory Group (Federal Government) › Gambling industry operators: - La Loterie Romande (Switzerland), Svenska Spel (Sweden), Club NSW (Australia), Comelot (UK), La Française des Jeux (France), Loto-Québec (Québec, Canada), Casino Austria, National Lottery (Belgium), Sportsbet, British Columbia Lottery Corporation, Aristocrat Leisure Industries › Organisations funded directly or indirectly from taxation &/or levies on industry: - Victorian Responsible Gambling Foundation, Ontario Problem Gambling Research Centre, Responsible Gambling Trust, Manitoba Gambling Research Program, & honoraria & expense reimbursement for training programs & workshops conducted from government funded problem gambling counselling services › Non-industry or non-government agencies: - National Association for Gambling Studies, National Council on Problem Gambling, Le Comité d'organisation Congrès international sur les troubles addictifs › All activities conducted with aim of enhancing responsible gambling policies & practices, training counsellors, & advancing knowledge of psychology of gambling
Integrated pathway model of problem gambling Its origin, evidence, & clinical & policy implications
30% to 50% of all scientific discoveries are to some extent serendipitous or ‘lucky’. (Dunbar et al. 2005) Most build upon existing findings BUT do so by questioning fundamental assumptions • Vulcanized rubber • Teflon • Nylon • Penicillin • Viagra • Microwave oven • Scotchgard • Safety glass
One question: how do we explain existing clinical & research findings?
First assumption: ?Homogeneity • Aetiological factors common to all gamblers • Environment, conditioning & cognitions • Vulnerability (personality traits, neurobiology)
Cultural & ecological
Second assumption: • Complex interaction of genetics, neurobiology, personality traits, life experiences, comorbid disorders, motivational, ecological & socio-cultural variables
Integrated Bio-Psycho-Social Model: Multiple interactive vulnerability factors Neurobiological/genetic Meso-limbic/orbito-frontal reward systems (shared with substance use) Family history Personality traits Modeling Exposure/attitude Coping strategies Trauma/rejection Belief schemas Peer group interactions 9 (Adapted from Shaffer et al, 2004)
Third assumption: • Motivations differ
• Skill games: action, egoism, alleviate boredom • Low skill: emotionally vulnerable seeking escape
Outcomes: explanatory models & subtyping Multiple single explanatory models: • Psychodynamic • Genetic/neurobiological • Behavioural • Cognitive Behavioural • Public health Multiple subtyping • Moran (1970) • Subcultural • Neurotic • Impulsive • Psychopathic • Neurotic 12
Integrated model of problem gambling To translate clinical experience & research findings into an effective framework guiding the management & treatment of gambling disorders
What is the integrated pathways model? 14
Pathways model: a brief overview • Socio-cultural/ethnic context of gambling determines attitudes/acceptance of gambling • Government regulatory framework dictates availability/access • Industry & media promotion increases attractiveness 15
Environment Behaviourally conditioned Emotionally vulnerable Biologically-based Arousal/excitement Emotional Cognitive schemas Neural escape substrates Coping style Differential reward/punishment & Impulsivity Pathological gambling Phenomenology: Affective disturbance, criminality, substance abuse, impaired relationships 16
Three pathways model (Blaszczynski & Nower 2002 ) 1. Behaviourally conditioned Reinforcement & cognitive distortions poor decisions 2. Emotionally vulnerable Relieve/modulate pre morbid aversive affective states + behaviourally conditioned 3. Biologically vulnerable Impulsivity, multiple maladaptive behaviours + behaviourally conditioned 17
Empirical data › Consistent support for three subgroups clustering predicted by the pathway model › Common components: Affect, impulsivity, cognitions & win experience - Gonzalez-Ibanez et al. (2003) - Ledgerwood & Petry (2006) - Stewart & Zack (2008) - Turner et al. (2008) - Bonnaire et al. (2009) - Vachon & Bagby (2009) - Ledgerwood & Petry (in press) - Nower, Martins, Lin, & Blanco (2013) (based on NESARC data analyses) - Valleur, et al. (2015)
› Differences across subtypes › Psychopathology - Pathway One : Symptoms causal outcomes of gambling-related problems & are amenable to psycho-education, brief interventions & brief CBT - Substantial role in Pathway Two : Affective disturbances, poor coping skills, & substance use pre-date & contribute to excessive gambling & require interventions - Biological predisposition linked to impulsivity in Pathway Three : Psychopharmacology & intensive interventions 19
Treatment implications 1. Assists clinicians in matching treatment to subtypes to increase cost efficiencies & effectiveness of service delivery 2. Focus on modifiable risk factors & less focus on non-modifiable factors (age, gender & genetics not modifiable but provide important information guiding treatment decisions & prognosis) 20
Adapted from Hodgins, D. (2005) Gambling Disorders Ready to change Not ready to change Identifying needs & matching gambler to appropriate level of • Family support care & services • Information brochures/signs • Media campaigns Self change Brief intervention Community/outpatient Intensive intervention
How do clinicians identify subtypes? › Careful consideration of: • Temporal sequence of gambling in relation to external factors & life experiences • Comorbid conditions & their interaction with PG • Bidirectional link: Depression, anxiety, alcohol & nicotine dependence (comorbidity weak predictive factor) • Impulsivity predictor of PG & driver for both PG & depression • Absence of psychiatric disorder protective factor against later PG • Predictive factors: continuous forms, past wins, family members (Williams et al., 2015) 22
Development of Pathways Questionnaire Nower & Blaszczynski › Multi-site clinical population study (n=1,170) - 127 items extracted from literature & expert review - Focus on temporal sequence of events - Exploratory, confirmatory & cluster factor analyses: correctly classified 88.6% - 48 items: Three factor model taking into account: • Anti-social behaviours • Impulsivity • Risk-taking • Emotional vulnerability • Stress-coping • Motivation • Child maltreatment
Pathways model policy implications › Shift in focus for media educational campaigns - Emphasis should be on improvement in quality of life - Majority of gamblers found in pathways 1 & 2 - Addictive model more applicable to Pathway 3
Pilot study measuring harms (n=542) Top ten gambling related harms by aggregate score: Gambling Effect Scale Items 1. Loss of savings 6. Hopelessness 2. Worry 7. Debt 3. Unhappiness/depression 8. Restricted leisure pursuits 4. Personal sense of loss of control 9. Relationship conflicts 5. Loss of self-respect 10. Poor sleep 25
Harms least commonly endorsed were: 1. Self-inflicted injury & suicide attempts 2. Bankruptcy 3. Eviction/loss of home Diminished quality of life (majority) vs serious/critical harms (minority) - Media campaigns target smallest proportion of gambling disorders - ?Explains why only 10-30% meeting criteria enter treatment at any time 26
Implications › Media campaigns ought to focus on less severe end of the harm spectrum - Normalize help-seeking behavior by avoiding stigmatization (distancing effects associated with fear/negative content) - Emphasize improvement in quality of life - Promote strength/courage of gambler in taking first steps in personal development 27
Positive educational campaign targeting majority › "You're Stronger Than You Think" promotes help-seeking as a sign of strength, not weakness, & reminds people that they have recovered from setbacks in the past & can do so again with the help of the free range of Gambling Help services http://www.gamblinghelp.nsw.gov.au/real-story/youre-stronger-than-you-think/?colour=yellow 28
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